Q&A: How to Prevent, Detect, & Treat Dehydration in Aging Adults

Q: How can we get my older mother to drink more water? She is susceptible to urinary tract infections and seems to be often dehydrated no matter what we do. We were also wondering if coffee and tea are okay, or should they be avoided to reduce dehydration?

A: Dehydration is indeed an important problem for older adults. It can be common even when it’s not hot outside.

Helping an older person increase her fluid intake, as you’re trying to do, is one of the best ways to reduce the risk of dehydration.

Now how to actually do this? Studies — and practical experience — suggest that the best approaches include:

Frequently offering the older person a drink, preferably on a schedule,

Offering beverages the person seems to prefer,

Not expecting older adults to drink a large quantity at a single sitting,

Addressing any continence issues that might be making the person reluctant to drink often.

But your question brings up other issues in my mind. Has frequent dehydration been confirmed? (Dehydration can be hard to correctly diagnose.) Have you been able to measure how much your mother drinks, and how does this amount compare to the recommended daily fluid intake for older adults?

Also, is the real goal to prevent or manage frequent urinary infections, and is increasing her hydration likely to achieve this?

So let’s review the basics of dehydration in older adults, and what’s known about helping older adults stay hydrated. I will then share some additional tips on helping your mother maintain hydration.

The Basics of Dehydration

What is dehydration and what causes it?

Dehydration means the body doesn’t have as much fluid within the cells and blood vessels as it should.

Normally, the body constantly gains fluid through what we eat and drink, and loses fluid through urination, sweating, and other bodily functions. But if we keep losing more fluid than we take in, we can become dehydrated.

If a person starts to become dehydrated, the body is designed to signal thirst to the brain. The kidneys are also supposed to start concentrating the urine, so that less water is lost that way.

Why are older adults at higher risk for dehydration?

Unfortunately, the body’s mechanisms meant to protect us from dehydration work less well as we age. Older adults have reduced thirst signals and also become less able to concentrate their urine.

Other factors that put older adults at risk include:

Chronic problems with urinary continence, which can make older adults reluctant to drink a lot of fluids

Memory problems, which can cause older adults to forget to drink often, or forget to ask others for something to drink

Mobility problems, which can make it harder for older adults to get something to drink

Living in nursing homes, because access to fluids often depends on the availability and attentiveness of staff

Swallowing difficulties

Dehydration can also be brought on by an acute illness or other event. Vomiting, diarrhea, fever, and infection are all problems that can cause people to lose a lot of fluid and become dehydrated. And of course, hot weather always increases the risk of dehydration.

Last but not least, older adults are more likely to be taking medications that increase the risk of dehydration, such as diuretic medications, which are often prescribed to treat high blood pressure or heart failure.

A UK study of older adults in residential care found that 46% had impending or current dehydration, as diagnosed by blood tests.

How is dehydration diagnosed?

In older adults, the most accurate way to diagnose dehydration is through laboratory testing of the blood. Dehydration generally causes abnormal laboratory results such as:

Elevated plasma serum osmolality: this measurement relates to how concentrated certain particles are in the blood plasma

(Doctors often sub-classify dehydration based on whether blood sodium levels are high, normal, or low.)

Dehydration can also cause increased concentration of the urine — this is measured as the “specific gravity” on a dipstick urine test. However, this is not an accurate way to test for dehydration in older adults, since we tend to lose the ability to concentrate urine as we get older. This was confirmed by a 2016 study, which found that the diagnostic accuracy of urine dehydration tests in older adults is “too low to be useful.“

There are also a number of physical symptoms associated with dehydration. However, a 2015 study of older adults found that the presence or absence of dehydration symptoms is not an accurate way to diagnose dehydration.

But as noted above: the presence or absence of these physical signs are not reliable ways to detect dehydration. Furthermore, the physical symptoms above can easily be caused by health problems other than dehydration.

So if you are concerned about clinically significant dehydration — or about the symptoms above — blood tests results may be needed. A medical evaluation for possible dehydration should also include an interview and a physical examination.

What are the consequences of dehydration?

The consequences depend on how severe the dehydration is, and perhaps also on how long the dehydration has been going on.

In the short-term, dehydration can cause the physical symptoms listed above. Especially in older adults, weakness and dizziness can provoke falls. And in people with Alzheimer’s or other forms of dementia, even mild dehydration can cause noticeable worsening in confusion or thinking skills.

Dehydration also often causes the kidneys to work less well, and in severe cases may even cause acute kidney failure.

The consequences of frequent mild dehydration — meaning dehydration that would show up as abnormal laboratory tests but otherwise doesn’t cause obvious symptoms — are less clear.

Chronic mild dehydration can make constipation worse. Otherwise, a 2012 review found that the only health problem that has been consistently associated with low daily water intake is kidney stones.

A 2013 review on fluid intake and urinary system diseases concluded that it’s plausible that dehydration increases the risk of urinary tract infections, but not definitely proven.

Speaking of urinary tract infections (UTIs), if you are concerned about frequent bacteria in the urine, you should make sure this reflects real UTIs and not simply a sign of the older person’s bladder being colonized with bacteria.

How is dehydration treated?

What type of electrolyte imbalances (such as high/low levels of sodium and potassium) appear on laboratory testing

If known, the cause of the dehydration

Mild dehydration can usually be treated by having the person take more fluids by mouth. Generally, it’s best to have the person drink something with some electrolytes, such as a commercial rehydration solution, a sports drink, juice, or even bouillon. But in most cases, even drinking water or tea will help.

Moderate dehydration is often treated with intravenous hydration in urgent care, the emergency room, or even the hospital. Some nursing homes can also treat dehydration a subcutaneous infusion, which means providing fluid through a small IV needle placed into the skin of the belly or thigh. This is called hypodermoclysis, and this is actually safer and more comfortable for seniors than traditional IV hydration.

Severe dehydration may require additional intervention to support the kidneys, and sometimes even requires short-term dialysis.

How to prevent dehydration in older adults?

I was unable to find research or guidelines clarifying which fluids are best to drink. This is probably because clinical research hasn’t compared different fluids to each other.

As to whether certain fluids are dehydrating: probably the main fluid to be concerned about in this respect is alcohol, which exerts a definite diuretic effect on people.

The effect of caffeine on causing people to lose excess water is debatable. Technically caffeine is a weak diuretic. But real-world studies suggest that people who are used to drinking coffee don’t experience much diuretic effect.

Now, caffeine may worsen overactive bladder symptoms, so there may be other reasons to be careful about fluids containing caffeine. But as best I can tell, coffee and tea are not proven to be particularly dehydrating in people who drink them regularly.

The safest approach would still be to drink decaffeinated drinks. But if an older person particularly loves her morning cup of (caffeinated) coffee, I’d say to consider accommodating her if at all possible.

How to help older adults to stay hydrated?

A 2015 review of nursing home interventions intended to reduce dehydration risk concluded that “the efficacy of many strategies remains unproven.” Still, here are some approaches that are reasonable to try:

Offer fluids often throughout the day; consider doing so on a schedule.

Offer smaller quantities of fluid more often; older adults may be reluctant to drink larger quantities less often.

Be sure to provide a beverage that is appealing to the older person.

See if the older person seems to prefer drinking through a straw.

Identify any continence concerns that may be making the older person reluctant to drink. Keeping a log of urination and incontinence episodes can help.

Consider a timed toileting approach, which means helping the older person get to the bathroom on a regular schedule. This can be very helpful for people with memory problems or mobility difficulties.

Track your efforts in a journal. You’ll want to track how much the person is drinking; be sure to note when you try something new to improve fluid intake.

Offer extra fluids when it’s hot, or when the person is ill.

Practical tips for family caregivers

Let’s now return to the issues brought up in the question.

Family caregivers are often concerned about whether an older person is drinking enough. Since dehydration is indeed very common among older adults, this concern if very important.

However, before expending a lot of energy trying to get your mother to drink more, I would encourage you to consider these four suggestions:

1.Measure how much your mother is actually drinking most days.

This can require a little extra effort. But it’s very helpful to get at least an estimate of how much the person drinks. This can confirm a family’s — or doctor’s — hunch that the person isn’t taking in enough fluid, and can help the care team figure out how much more fluid is required.

Again, the recommendation for older adults is to consume at least 1.7 liters/day, which corresponds to at least 57.5 fluid ounces. In the US, where a measuring cup = 8 ounces, this is equivalent to 7.1 cups/day.

Keep a journal to record how much fluid your older parent is drinking. It’s generally important to track anything you want to improve.

2. Confirm that your mother is, in fact, often dehydrated.

As noted above in the section on diagnosing dehydration: physical symptoms and urine tests are not enough to either diagnose dehydration or rule it out.

Instead, consider these two approaches to confirming clinical dehydration. One is to see if her energy and mental state perk up when she drinks more. The other is to talk to the doctor and request blood tests to confirm dehydration.

Now, you don’t necessarily want to request blood tests every time you suspect mild dehydration. But especially if your mother’s dehydration has never been confirmed by a serum osmolality test, it would probably be useful to do this at least once.

3. If frequent urinary tract infections (UTIs) are a concern, learn about asymptomatic bacteriuria and try to determine whether these are real UTIs versus a colonized bladder.

Sometimes I’ve seen families hellbent on increasing hydration or taking other measures, because they are concerned about repeated or persisting urinary tract infections (UTIs).

But UTIs are a bit like dehydration. A UTI is a common problem in older adults and is potentially very serious. But it’s also easily misdiagnosed, even by professionals.

Sometimes, when an older person keeps being diagnosed with a UTI repeatedly, the problem is actually that the older person has asymptomatic bacteriuria. This is a very common condition in which an older person’s bladder becomes colonized with bacteria. It probably happens because people’s immune systems get weaker as they age.

So how is this different from a UTI? Both conditions will cause a positive urine culture, meaning that bacteria is in the urine. The main difference is that in asymptomatic bacteriuria, the older person doesn’t experience pain, inflammation, increased confusion, or other symptoms of infection.

In a young person, bacteria in the urine is very uncommon and almost always corresponds to a clinically significant infection. But in an older person, bacteria in the urine is common.

So you cannot diagnose a UTI in an older person just on the basis of a positive urine culture. Instead, the family and clinician must note other signs of infection, such as pain or delirium.

Families are often surprised to learn that clinical trials have repeatedly found that it is not helpful to treat asymptomatic bacteriuria, but it’s true. In fact, a 2015 study found that treating asymptomatic bacteriuria with antibiotics increased the likelihood of later having a real UTI, and that the real UTI was more likely to be antibiotic-resistant.

4. Pay attention to figure out which fluids your mother prefers to drink and try scheduling frequent small drinks.

Ultimately, there’s no substitute for paying close attention, keeping track of your observations, and doing some trial and error to figure out what seems to improve things.

No doctor has a magic formula to get an older person to drink more. So identify the drinks your mother prefers, start tracking how much she drinks, and then start experimenting to figure out what works.

Usually, a combination of the following three approaches will improve fluid intake:

Offer a beverage the person likes,

Offer small-to-moderate quantities of the beverage on schedule,

Address continence issues.

Do you have any additional questions regarding the prevention of dehydration in older adults?

Comments

drink at least 1.7 liters/day, which corresponds to at least 57.5 fluid ounces. In the US, where a measuring cup = 8 ounces, this is equivalent to 7.1 cups/day.

After reading this, I poured 7.1 cups of water in a bowl. There is no way this is the correct amount to DRINK in a day. It has to be way too much. Maybe if one counts the moisture in ALL the food one eats as well. This reminds me of the “urban myth” that has been debunked that one should drink 8 cups of water a day. Everyone repeated this because they thought it was backed up by research but, it wasn’t and turned out to be an interesting case study in how directives enter into commonly accepted wisdom.

Thanks for bringing up this point. When I researched the post it was a bit unclear to me whether the daily fluid recommendation was supposed to include food or not. Also true that many medical myths are out there, and the “8 glasses of water per day” one was thoroughly debunked by Dr. Aaron Carroll in the NYT in 2015.

In terms of research, as far as I know, no one has randomized older adults to receive more than 1.7L/day versus less, and seen what happened.

But this study did randomize men aged 55-75 to drink an extra 1.5L/day; this extra intake did not improve outcomes. The full article (behind a firewall, sorry) reports that at baseline, participants had a daily fluid turnover of 3 liters/day. (They used a fancy “deuterium-labeled water method” to measure fluid turnover, so this measurement should be fairly accurate.) So this might be consistent with drinking 1.5/L and getting the other 1.5L through food.

What we DO know is that many older adults ARE at least mildly dehydrated, especially those who are older, frailer, or cognitively impaired. (The NYT’s Dr. Carroll is very smart but he is a pediatrician, which colors his clinical expertise, plus most clinical research is not conducted in people like the questioner’s mother.) Those older people likely would benefit from an increase in daily fluid intake. The true answer to how much they should drink is “however much usually keeps them from being dehydrated per their labs.” But since this is not feasible to measure for everyone, it seems reasonable to keep the guideline of 1.7L/day in mind.

I manage a home health agency and dehydration is, indeed, a very common challenge encountered by us. This is a wonderful and complete article. Thank you! I would add that sneaking watery foods into the diet may help, too. Watery fruits and soups (especially nice warm soup on a cold day) may help add needed water into the diet–just watch the sodium content. Also, people are more willing to take in extra water with medications if you tell them it is medically necessary. Anytime a medical professional says to do something, people are more inclined to do it.

For mild dehydration, drinking just about any kind of fluid — including plain water — will help. A fluid that contains electrolytes may be more effective, and would be more important if the dehydration is worse than mild.

My father, who is 91 years old, was just released from hospital. They could not find any cause for his dilirium but administered intravenous fluids as a precaution. After 3 days he returned to normal. We encouraged him to drink more water (which he did while we were there). This is not the first episode my father has had with dilirium and each time it happens the hospital has no prognosis but again administers intravenous fluids as a precaution. These episodes are far more serious than we were aware of, thank you for sharing your knowledge of these issues. We will continue encouraging my father to drink fluids more often. He is also taking Boost on a daily basis but I wonder just how much good this product does as opposed to drinking just plain old water.

As I say in the article, experts generally recommend older adults consume 1.7 liters of fluid per 24 hours.

If a person is actually dehydrated, how much liquid is needed and how long it takes to rehydrate depend on many things, including how significant is the dehydration, the underlying cause, and the person’s ability and willingness to drink fluids.

What can you do when your mother will not drink because she has to urinate frequently and thinks that she won’t have to go as often? I told her that it’s not uncommon to have more bathroom trips but she will not drink more than 3 small glasses per day.

That’s not uncommon, but it certainly can be challenging to work through. If her continence issues are the main concern, then I would recommend focusing on that and helping her address them.
First, she should be evaluated to determine what’s causing her frequent urination and to see if any medications or other health-related issues are aggravating her continence issues.

How to manage incontinence really depends on what the underlying causes are. But in general, timed toileting and bladder training are helpful in many circumstances.

Finding a suitable and comfortable incontinence pad can also help quite a lot, especially for trips out of the house or any other situation that creates worry about “what if I need to go?”

Lastly, in terms of general strategy in persuading an older person, it’s important to try to avoid lecturing and power struggles. Try to start by inviting your mom to share her thoughts and concerns, ask her what she thinks might help, and be sure to use “I messages” when you voice your concerns, rather than “you should” messages. Good luck!

Thanks for sharing this formula. This formula would suggest an intake of 1.9 liters for someone of my weight, which is about 8 cups of water and that’s just a cup more than the 1.7 liters/day suggestion in the article.

Dear Leslie, I have written to you before and am grateful for your site. Alimentary canal blocked today after drinking extra water. Had a yucky episode with severe reflux propelling body to the toilet. My chief concern has to do with the bowel. Last week I cancelled a colonoscopy. At nearly 85, COPD, problems with other (? Most) body systems, decided it was too risky. After the above episode was able to pass stools and eventually urine … lately have had fluid retention and mild constipation. At the end of las toilet visit there were, what looked like, dark grains ? from multi grain bread; now concerned they could be what some refer to as coffee grounds. I have no idea what the last things look like when connected to bowel cancer. Also for some weeks have post natal drip which is very annoying…thickish, clear, no odour. In Australia visits to the Doctor are ‘time rationed’, chipping into confidence. Thank you for your help.

Glad you find the site helpful. If you are concerned about potential blockage of the bowel sounds more like constipation than dehydration (although dehydration can certainly make constipation worse). More on constipation here: How to Evaluate, Prevent & Manage Constipation in Aging.

Re “coffee grounds”, there is a phenomenon called “coffee ground emesis”, it is something people vomit sometimes when they are having bleeding in the upper gastrointestinal tract. When blood from the upper part of the bowel eventually exits from below, it is called “melena” and it looks dark and tarry, due to the effect of the body’s digestion on the blood. “Dark grains” in the feces doesn’t ring any bells for me in terms of signs of bleeding or bowel cancer. It certainly is common for small bits of indigestible material (e.g. the outside of corn kernels) to show up in the feces.

You mentioned in a prior comment that you are “all alone.” I would say that a bigger issue to address in this case is how can you get extra help and support regarding your health concerns, and who could support you if you were unwell. I’m not sure what the options are in Australia. For someone in the US, I might suggest looking into local community groups for aging adults and local non-profits. Churches sometimes sponsor such groups. Some people also get a lot of benefit from connecting with others online, either people with a similar social situation or with similar health problems.

In the US, we also have privately paid services, such as patient advocates (for help sorting out a health concern) and in California, professional fiduciaries (for help overseeing general affairs and sometimes medical affairs as well).

I suppose what I am saying is that although it’s certainly valuable to use the internet to research specific health conditions and concerns, this can’t substitute for having support in navigating the medical experience, and eventually, in navigating other late-life challenges. So I would encourage you to research options for finding that support in your area. Good luck and take care!

When I trained as an EMT, we were taught a quick “test” for dehydration–gently pinching the skin of a person’s forearm between our thumb and first finger. If the skin subsides, the person is probably OK. If the skin stays in that puckered position, dehydration might be occurring.

Hi Leslie, A member of my family had dementia. As things got worse they had to be cared for in a nursing home. They werent happy about this but there was no other option . Although they were still full of life and a good laugh. Loved by both staff and residents. After about 7/8,weeks they started to become dehydrated. So week later were given iv fluids for 3 days i think. It turns out when tested after the iv they were still badly dehydrated . A week later the doctor had to be got again and less they five days later they died. Why would the iv not have worked and how come they went down hill so quickly?

Sorry to hear of your relative’s decline and death. When it comes to more significant dehydration — or more significant illness, which can cause a need for IV fluids — there are all kinds of possibilities so it’s really not possible for me to say what happened. From what you describe, I think it’s quite possible that there was more going on than just a need for rehydration with normal saline.

To learn more about what happened, you could try asking the involved health providers to explain in a little more detail. Alternatively, your family might be able to request the medical records and have them reviewed by a medical expert, who could then perhaps explain.

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